Technologies for Legionella Control in Premise …

1 Office of Water EPA 810-R-16-001 September 2016 Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review Office of Water (4607M) EPA 810-R-16-001 September 2016 Disclaimer The Environmental Protection Agency (EPA) prepared this document to serve as a technical resource for primacy agencies, facility operators and facility owners to use as they evaluate Technologies to respond to the risks associated with Legionella growth in Premise plumbing systems. This document summarizes peer-reviewed scientific literature , reports from nationally and/or internationally recognized research organizations, and guidelines and standards from nationally and/or internationally recognized organizations on the characterization of the effectiveness against Legionella of different Technologies that may be used to Control Legionella growth in Premise plumbing systems. The document provides information about water quality issues that could result when using the various Technologies and summarizes operational conditions for each technology.

2 It also discusses critical risk management approaches to address microbial (including Legionella ), physical and chemical risks in various parts of the Premise plumbing system, such as water management programs (WMPs), hazard analysis and critical Control point (HACCP), water safety plans (WSPs) and industrial hygiene principles. This document provides an overview of other strategies that can be used to Control Legionella growth when addressing a public health threat such as a Legionella outbreak. It does not apply to households but rather to commercial and institutional facilities. This document is not a regulation; it is not legally enforceable; and it does not confer legal rights or impose legal obligations on any party, including EPA, states or the regulated community. While EPA has made every effort to ensure the accuracy of any references to statutory or regulatory requirements, the obligations of the interested stakeholders are determined by statutes, regulations or other legally binding requirements, not by this document.

3 In the event of a conflict between the information in this document and any statute or regulation, this document would not be controlling. Although this document describes Technologies for controlling Legionella growth in Premise plumbing systems, the information presented may not be appropriate for all situations and alternative approaches may be applicable. Mention of trade names or commercial products does not constitute an EPA endorsement or recommendation for use. This page intentionally left blank. Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review i Table of Contents Table of Contents .. i Table of Exhibits .. iv Abbreviations and Acronyms .. v Acknowledgements .. vii Preface .. ix Executive Summary .. 1 1 Background .. 5 Purpose and Scope .. 5 Legionella : Overview .. 5 General Information .. 5 Epidemiology and Pathogenesis.

4 6 Ecology and Physiology .. 8 Legionella Occurrence and Risk from the Distribution Systems and Premise Plumbing Systems .. 10 Regulatory Context .. 13 2 Risk Management Approaches and Technologies to Control 15 Overview of Current State of Knowledge .. 15 Risk Management Approaches .. 17 Background .. 17 Applications of Risk Management Approaches .. 18 Temperature Approach for Legionella Control .. 20 Environmental Testing .. 22 Technologies .. 25 Chlorine .. 25 Background .. 25 Characterization of Effectiveness against Legionella .. 26 Potential Water Quality Issues .. 32 Operational Conditions .. 33 Monochloramine .. 34 Background .. 34 Characterization of Effectiveness against Legionella .. 35 Potential Water Quality Issues .. 41 Operational Conditions .. 43 Chlorine Dioxide .. 45 Background .. 45 Characterization of Effectiveness against Legionella .

5 45 Potential Water Quality Issues .. 48 Operational Conditions .. 49 Copper-Silver Ionization .. 51 Background .. 51 Characterization of Effectiveness against Legionella .. 52 Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review ii Potential Water Quality Issues .. 55 Operational Conditions .. 56 Ultraviolet Light Disinfection .. 58 Background .. 58 Characterization of Effectiveness against Legionella .. 59 Potential Water Quality Issues .. 60 Operational Conditions .. 61 Ozone .. 62 Background .. 62 Characterization of Effectiveness against Legionella .. 63 Potential Water Quality Issues .. 64 Operational Conditions .. 65 3 Other Strategies Used to Control for Legionella .. 67 Emergency Remediation .. 67 Superheat-and-Flush Disinfection .. 67 Background .. 67 Characterization of Effectiveness against Legionella .

6 67 Potential Water Quality Issues .. 70 Operational Conditions .. 70 Shock Hyperchlorination .. 71 Background .. 71 Characterization of Effectiveness against Legionella .. 72 Potential Water Quality Issues .. 73 Operational Conditions .. 73 Point-of-Use Filtration .. 74 Background .. 74 Characterization of Effectiveness against Legionella .. 76 Potential Water Quality Issues .. 77 Operational Conditions .. 78 4 Questions and Answers on Legionella Control in Premise Plumbing Systems .. 79 Public Health Concerns .. 79 Potential Regulatory Requirements .. 79 Control Measures .. 81 New Technology Approval .. 83 Permitting .. 83 Sampling and Monitoring .. 84 Operator Certification .. 85 Unintended Consequences .. 85 Additional Sources of Information .. 85 5 References .. 87 Appendices .. 117 Types of Studies by Technology.

7 117 Elements of Hazard Analysis and Critical Control Points .. 122 Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review iii Elements of a Water Management Program .. 123 Water Safety Plan Modules .. 124 Elements of the American Industrial Hygiene Association Assessment Approach .. 125 Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review iv Table of Exhibits Exhibit 1-1: Legionella transmission .. 7 Exhibit 2-1: UV doses (mJ/cm2) for inactivation of L. pneumophila .. 60 Exhibit 3-1: Membrane filtration guide for removal of microbial contaminants .. 75 Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review v Abbreviations and Acronyms AIHA American Industrial Hygiene Association ASTM American Society for Testing and Materials ANSI American National Standards Institute AOC Assimilable organic carbon ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers ATP Adenosine triphosphate AWWA American Water Works Association C Celsius CDC Centers for Disease Control and Prevention CFR Code of Federal Regulations CFU Colony-forming units CSI Copper/silver ionization CT Disinfectant residual concentration C multiplied by the contact time T (C T)

8 DBP Disinfection byproduct D/DBPR Disinfectants and Disinfection Byproducts Rule DPD N,N-diethyl-p-phenylenediamine DNA Deoxyribonucleic acid DS Distribution system ECDC European Centre for Disease Prevention and Control ELITE Environmental Legionella Isolation Techniques Evaluation EP Entry point to the distribution system EPA United States Environmental Protection Agency EPDM Ethylene-propylene diene-monomer F Fahrenheit FIFRA Federal Insecticide, Fungicide and Rodenticide Act GWR Ground Water Rule HAA Haloacetic acid HACCP Hazard analysis and critical Control points HDPE High density polyethylene HPC Heterotrophic plate count HOCl Hypochlorous acid HSE Health and Safety Executive of the United Kingdom ICP/MS Inductively coupled plasma/mass spectrometry ICU Intensive care unit km Kilometers LP Low pressure MCL Maximum contaminant level MF Microfiltration mg/L Milligrams per liter mJ/cm2 Millijoule per square centimeter mM Millimolar MP Medium pressure Technologies for Legionella Control in Premise Plumbing Systems.

9 Scientific literature review vi MRDL Maximum residual disinfectant level NDMA N-nitrosodimethylamine NF Nanofiltration NSF NSF International OCl- Hypochlorite ion OSHA Occupational Safety and Health Administration PCR Polymerase chain reaction POE Point-of-entry POU Point-of-use PWS Public water system qPCR Quantitative polymerase chain reaction RO Reverse osmosis rRNA Ribosomal ribonucleic acid SDWA Safe Drinking Water Act SMCL Secondary maximum contaminant level spp. Plural of species SWTR Surface Water Treatment Rule THM Trihalomethane TTHM Total trihalomethanes Micron (millionth of a weight, distance and/or volume unit) g/L Micrograms per liter m Micrometer UF Ultrafiltration United States UV Ultraviolet UVT UV transmittance VBNC Viable but non-culturable VHA Veterans Health Administration WHO World Health Organization WMP Water management program WSG Water supply guidance WSP Water safety plan Technologies for Legionella Control in Premise Plumbing Systems: Scientific literature review vii Acknowledgements EPA s Office of Ground Water and Drinking Water would like to thank the Association of State Drinking Water Administrators; the States of Maryland, Minnesota, Nevada, New York, Ohio, and Pennsylvania; and the Centers for Disease Control and Prevention for their contributions to this document.

10 EPA thanks these participants for their input, which was critical for the development of this document. The following individuals helped to develop and/or review this document: Darrell Osterhoudt (Association of State Drinking Water Administrators) Laurel Garrison (CDC) Natalia A. Kozak-Muiznieks (CDC) Claressa Lucas (CDC) Philip Berger ( EPA) C sar Cordero ( EPA)1 Leslie Darman ( EPA) Michael Elovitz ( EPA) Michael Finn ( EPA)1 John Hebert ( EPA) Darren Lytle ( EPA)1 Thomas Grubbs ( EPA)1 Hannah Holsinger ( EPA)1 Jingrang Lu ( EPA) Emily Mitchell ( EPA) Pritidhara Mohanty ( EPA)1 Mark Perry ( EPA) Stacy Pfaller ( EPA)1 Jonathan Pressman ( EPA) Stig Regli ( EPA) Mark Rodgers ( EPA)1 Crystal Rodgers-Jenkins ( EPA)1 Kenneth Rotert ( EPA) Nicole Shao ( EPA) Alysa Suero ( EPA) Lili Wang ( EPA)1 Saeid Kasraei (Maryland Department of the Environment) Jerry Smith (Minnesota Department of Health) Jennifer Carr (Nevada Division of Environmental Protection)1 Ross Cooper (Nevada Division of Environmental Protection)1 Neculai Codru (New York State Department of Health) David Dziewulski (New York State Department of Health)